KC OB Flashcards
(113 cards)
1
Q
*Pregnant woman 32 weeks with uterine tenderness, uterine firmness and vaginal bleeding: 4 Ddx
A
- Placental abruption
- Placenta previa
- Early labor (bloody show)
- Cervical/vaginal lesion
2
Q
*Pregnant woman 32 weeks with uterine tenderness, uterine firmness and vaginal bleeding: would you do a spec? Why or why not?
A
Digital or instrumental probing of cervix should be avoided until the diagnosis of placenta previa is excluded by ultrasound as severe bleeding can be precipitated
Speculum exam should only be performed in those settings in which obstetric consultation is not readily available
3
Q
*How sensitive is ultrasound for detecting placental abruption? Give a number.
A
Per UpToDate: “The sensitivity of ultrasound findings for diagnosis of abruption is only 25 to 60 percent”
4
Q
*Pregnant woman 32 weeks with uterine tenderness, uterine firmness and vaginal bleedin: She becomes hypotensive and unstable. 4 management at this point
A
- IV crystalloid resuscitation
- Administration of blood products (umatched O negative blood, unless group and screen done)
- OB/GYN consultation
- Fetal monitoring
- Correction of coagulopathy
5
Q
*List three medications to treat high blood pressure in preeclampsia
A
Per SOGC:
• Labetolol, start with 20 mg IV
• Nifedipine, 5 to 10 mg capsule
• Hydralazine, start with 5 mg IV
6
Q
*What 4 lab tests would you order in a patient with pre-eclampsia?
A
CBC
LFTs
Creatinine
Urinalysis
Coag
7
Q
*2 antihypertensive medications (or class) contraindicated in 1st trimester, and what congenital disorder they are associated with?
A
ACEi, ARB - Potter’s syndrome (renal agenesis) … I think this is what theyre asking for
8
Q
*5 RF for ectopic pregnancy
A
Anatomic/surgical abnormaliti- Anatomic/surgical abnormalities: previous ectopic, prior tubal surgery (sterilization or ectopic), pelvic surgery with pelvic adhesions,
Conception: IUD, in vitro fertilization, infertility, previous abortion/miscarriage
Patient: PID, smoking, endometriosis, advanced agees: previous ectopic, prior tubal surgery (sterilization or ectopic), pelvic surgery with pelvic adhesions,
9
Q
*What are 4 findings on ultrasound to diagnose an IUP?
A
- Intrauterine decidual reaction and gestational sac
- Intrauterine yolk sac
- Intrauterine fetal heart activity
- Myometrial mantle of at least 5 mm
- Uterine-bladder juxtaposition
10
Q
*2 finding on ultrasound suggestive of ectopic pregnancy?
A
Extrauterine gestational sac, yolk sac, fetal pole, or cardiac activity
Pseudo-gestational sac, a gestational sac without a yolk sac
If patient unstable:
Intra-abdominal free fluid
11
Q
*What are two management priorities in unstable ruptured ectopic?
A
IV fluids/blood
Immediate surgery
12
Q
*When in pregnancy does the risk of PID substantially decrease?
A
PID is very rare in pregnancy and does not occur after the first trimester.
13
Q
*32 weeks G1P0 with BP 230/115 and severe refractory headache. Presumptive diagnosis? 2 medications for her at this time?
A
Pre-eclampsia
1. Mg»_space;> labetalol
2. Steroids for baby
14
Q
*5 risk factors Pregnancy-Induced Hypertension (Preeclampsia and Eclampsia)
A
The risk of pregnancy-induced hypertension is greatest in women:
- Pregnancy: primigravida, new partners,multiple gestation, extremes of maternal age <18 or >35
- Pre-existing: HTN, renal disease, diabetes, antiphospholipid syndrome, obesity
- Hx of the same, previous HTN in pregnancy, family hx of pregnancy induced hypertension
15
Q
*In a woman with RUQ pain and pregnancy how would you distinguish based on BW AFLP versus HELPP?
A
- AFLP has raised LFTs with normal platelets, Cr also often raised
- HELLP has low platelets
3 Transaminitis tends to be much higher in AFLP than in HELLP
16
Q
*How long after delivery can you present with eclampsia?
A
6 weeks
17
Q
*5 RF for abruption
A
Maternal age younger than 20 or 35 years of age or older,
Parity of three or more,
Unexplained infertility,
History of smoking,
Thrombophilia,
Prior miscarriage,
Prior abruptio placentae,
Cocaine use.
18
Q
*8 week pregnant G2P1; Vaginal bleeding, abdo Pain, HD stable. What are the 3 most important blood tests to order
A
- CBC
- BhCG
- Group and screen
19
Q
*Gestational sac is 18 mm and irregular. What are 3 things on your DDX.
A
- Ectopic pregnancy
- Incomplete miscarriage
- Anembryonic pregnancy (blighted ovum >25mm)
- Early IUP
20
Q
*Her BHCG is 230,000. What is the most likely diagnosis.
A
Molar pregnancy
21
Q
*4 causes cardiac arrest in pregnancy
A
BEAU-CHOPS
- Bleeding/DIC
- Embolism (cardiac/pulmonary/amniotic fluid)
- Anesthetic complications
- Uterine atony
- Cardiac disease: MI/ischemia/aortic dissection/cardiomyopathy
- Hypertension/pre-eclampsia/eclampsia
- Other: all the Hs and Ts of standard ACLS
- Placental abruption, previa
- Sepsis
22
Q
*What three features define preeclampsia
A
• Pregnancy at 20 weeks gestational age or later
• Gestational hypertension (140/90 mmHg or higher and previously normotensive)
• Proteinuria (300 mg/24 hours) OR (new since 2013): other end organ damage –> thrombocytopenia; incrs LFTs, pulmonary edema, visual disturbance, AKI
23
Q
*List five maternal complications of preeclampsia. What are 4 complications specifically for baby?
A
Eclampsia/seizures/death
- Heme: Thrombocytopenia, DIC,Elevated liver enzymes, LDH,HELLP (hemolysis, elevated liver enzymes, low platelets)
- Renal: Oliguria, renal failure
- Neuro: Headaches, visual disturbances, hyper-reflexia, stroke, seizures, convulsions
- Resp: pulmonary edema
- Abdo: Hepatic failure, jaundice
- Baby: placental abruption: bleeding, decreased fetal movement, IUGR, Oligohydramnios
24
Q
*Most important questions to ask mother who presents crowning
A
1) Gestation Age (i.e. younger = need for NICU resus)
2) PROM bleeding (i.e. expected fetal distress on arrival due to bleeding, acidosis, hypoxia, multi-system insult)
25
*5 manoeuvres for shoulder distocia
HELPER pneumonic
H- call help
E- episiotomy
L- Leg’s up (McRobert; knee to chest position)
P- Pubic pressure (i.e. suprapubic)
E- enter the vagina (Rubins and Wood’s corkscrew). Rubin: pushing most accessible shoulder towards the fetal chest. Wood's: impacted shoulder is release through rotation of the fetus 180 degrees
R- remove the post arm
26
*What are the 4 stages of labour
Stage 1: <10cm dilation, latent phase + active phase. The first stage of labor is the cervical stage, ending with a completely dilated, fully effaced cervix.
Stage 2: full dilation -> baby out. Fully dilated cervix and accompanied by the urge to bear down and push with each uterine contraction.
Stage 3: baby born -> delivery of placenta, frequent checks of the tone and height of the uterine fundus.
Stage 4: 1 hour post partum, critical period during which postpartum hemorrhage is most likely to occur.
27
*What are 3 causes of post partum hemorrhage? Which is most common?
“four Ts”— t one, t rauma, t issue, and t hrombin
Accounting for 75% to 90% of cases, the most common cause of serious immediate postpartum hemorrhage is laxity of the uterus after delivery.
28
*What are 5 physiological changes in pregnancy that are going to impact your intubation and mechanical ventilation?
40% increase in minute ventilation
Decreased vital capacity
Mild resp acidosis
Flared ribs - predisposition to PTX and faster progression to tension PTX
reduced oxygen reserve (FRC)
increased 02 consumption
increased oxygen demand during apnea by 30%
increase minute ventilation leads to hypocapnia (so a paCO2 of 35 is abnormal…!)
need RAPID RSI,
BVM is super tough, vent pressures higher
Delayed GI empyting - risk of asp.
29
*Trauma patient, pregnant, with profuse vaginal bleeding and FHR decreased. Presumed Dx?
Placental abruption
30
What is the discriminatory zone and when should an intrauterine pregnancy be visible on ultrasound?
Transvaginal: gestational sac should be visible once BHcG reaches 1500, or 5 weeks
Transabdominal: gestational sac should be visible once BHcG reaches 6500 or 6-8 weeks
31
List 3 differentials each for a lower and higher than expected BhCG
Lower: ectopic, abortion, inaccurate dates
Higher: multiple gestations, molar pregnancy, trisomy 21
32
When should an embryo with cardiac activity be visible on US
Transvaginal: 6 weeks BHcG >10,000 - 20,000
Transabdominal: 7 weeks, BHcG >20,000
33
What are 2 ultrasound criteria for embryonic demise
Intrauterine gestational sac >25mm with no embryo
CRL >7mm with no cardiac activity
34
List 5 sonographic criteria of an abnormal pregnancy via transvaginal ultrasound
No gestational sac when BHcG >3000, no yolk sac with gestational sac >13mm or 32 days LMP, no fetus with gestational sac >25mm, no fetal heart tones with 5 mm CRL, no fetal heart tones with gestational age 10-12 weeks
35
What qualifies a determinate scan for intrauterine pregnancy
Bladder uterine juxtaposition, centrally located gestational sac >25mm, yolk sac and/or fetal pole (double ring sign)
*gestational sac alone is not an IUP; can be a pseudogestational sac
36
What dose of Rhogam should be given in first trimester bleeds? In later trimesters?
120 uG, 300uG
37
A patient is diagnosed with an ectopic and is interested in medical management. What patient factors make this safe?
Hemodynamically stable, minimal abdominal pain, able to follow up reliably, have a tubal mass <3.5cm in diameter, no fetal cardiac activity, no sonographic signs of rupture, and have normal baseline liver function
38
List 10 risk factors for miscarriage
Increasing maternal or paternal age, maternal anatomic abnormalities (ex. Fibroids, uterine scarring, cervical incompetence), prior miscarriage, increased parity, vaginal bleeding in pregnancy, toxins (alcohol, cocaine), maternal infections, autoimmune disease, substance use, maternal comorbidities (poorly controlled diabetes, thyroid disease, obesity or low body mass)
39
Differentiate complete, incomplete, missed, threatened, and inevitable miscarriages
Complete: OS closed, tissue all passed, no FHR, no retained tissue, not viable
Incomplete: OS open, bleeding and cramping, no FHR, some retained tissue, not viable
Missed: OS closed, no symptoms, no FHR, fetal demise in utero, not viable
Threatened: OS closed, bleeding, FHR, viable but at risk
Inevitable: OS open, bleeding, +/- FHR, not viable
40
What is a molar pregnancy? What are 4 clinical presentation features?
Proliferation of chorionic villi. Complete: fertilization of ovum with no maternal DNA. Partial: fertilization of ovum with two sperm. Presents with bleeding, hyperemesis, abnormally high bHcG levels, 'snowstorm' appearance on ultrasound
41
What is placental abruption
Separation of the placenta from the uterine wall, due to spontaneous hemorrhage or traumatic separation
42
List 5 complications of placenta abruption
DIC (due to fibrinogen drop), fetomaternal transfusion, amniotic fluid embolism, fetal death c/o impaired blood flow, maternal death c/o coagulopathy
43
List 5 risk factors for placenta previa
Increased maternal age, smoking, multiparty, C section, prior miscarriage, preterm labour
44
How would you differentiate between placental abruption and placenta previa
Pain, ultrasound (for previa), fetal distress
45
What is an abnormal blood pressure in pregnancy
>140/90 (severe if >160/110)
46
What is gestational hypertension
BP> 140/90 diagnosed after 20 weeks gestation without proteinuria or signs of end organ dysfunction
47
What is eclampsia
Preeclampsia + seizures
48
List 4 antihypertensives that should be avoided during pregnancy
ACE, ARB, BB in T1, prolonged nitroprusside (fetal cyanide)
49
What are 3 signs of magnesium toxicity and what is the antidotes
Decreased reflexes, respiratory depression, hypotension (other side effects: nausea/vomiting, weakness, bradycardia)
Calcium gluconate 1-2 amps IV
50
What are 5 potential precipitants of an amniotic fluid embolism
Abortion, miscarriage, spontaneously, uterine contractions in labour (most common), amniocentesis, placental abruption
51
List 5 differentials for abdominal pain in pregnancy
Obstetrical: miscarriage, septic abortion, ectopic, chorioamnionitis, preeclampsia, placental abruption
Gynecologic: corpus luteum cyst, ovarian torsion, PID
Non gynecologic: appendicitis, cholecystitis, hepatitis, pyelonephritis
52
List 3 differentials for jaundice in pregnancy
Cholestasis of pregnancy, hepatitis, acute fatty liver
53
Name two risk factors for acute fatty liver of pregnancy
Primis, twin pregnancy
54
List 3 lab abnormalities that can be expected in hyperemesis gravidarum
hypokalemia, hypomagnesemia, hypochloremic metabolic acidosis, ketonuria
55
List 5 medications that can be used in the treatment of hyperemesis
Ginger 250 mg PO Q6, Diclectin (Pyridoxine/Doxylamine 10mg/10mg tabs), Diphenhydramine, Metoclopramide, Ondansetron
56
Describe the use of D dimer in pregnancy, citing relevant literature
Pregnancy adapted YEARS
van der Pol LM, et al. N Engl J Med. 2019 Mar 21;380(12):1139-1149
Population: 510 pregnant patients >18 in the ED or obstetrical ward for ?PE
Intervention: YEARS algorithm. If all criteria negative 1) signs of DVT 2) patient have hemoptysis 3) PE most likely diagnosis a higher D dimer threshold of 1000 can be used. CTPA or US was then ordered for further workup as needed
Control:
Outcome: Incidence of symptomatic VTE in 3 mo follow up -> PE was ruled out in 96% of patients, 1 patient was diagnosed with a popliteal DVT on day 90. Secondary outcome includes proportion of patients who did not require a CT based on algorithm -> 39% avoided a CT scan.
Limitations: not exclusively an ED population, results of D dimer may have been known to clinicians
Bottom line: Pregnancy adapted years can be safely used to rule out PE
57
What is the preferred anticoagulant for thrombosis in pregnancy
Low molecular weight heparin (do not cross the placenta)
LMWH preferred over UFH as lower risk of osteoporosis, lower rate of bleeding
58
List 2 antibiotics, commonly used in the treatment of UTIs, that should be avoided in pregnancy
Nitrofurantoin should be avoided in T1 (teratogenic) and late pregnancy (hemolytic anemia)
Septra should be avoided in TQ (teratogenic) and late pregnancy (kernicterus)
Fluoroquinolones should always be avoided (cardiac toxicity)
59
List 5 infectious diseases and their associated congenital abnormalities in pregnancy
TORCH
Toxoplasmosis: Associated with raw meat, cat feces. Results in chorioretinitis, hydrocephalus, mental disorders, seizures, jaundice
Other - Syphilis: Congenital syphilis; hepatosplenomegaly, osteochondritis, jaundice, Hutchinson's teeth
Other - Parvovirus: anemia, hydrops, miscarriage
Rubella: hearing loss, cataracts, heart disease, hepatitis
CMV: Associated with day care workers, moms often asymptomatic. Results in hydrocephalus, microcephaly, deafness, chorioretinitis
Herpes Simplex V: disseminated herpes in newborns, encephalitis
60
List 3 methods of HIV transmission to the newborn
Antepartum, intrapartum (consider C section), post partum (breast feeding)
61
List 5 factors that increase the risk of HIV transmission to the newborn
Viral load, breast feeding, mode of delivery (SVD vs. C section), prolonged ROM, antiviral medications
62
List modifications to HAART for pregnancy patient
Should include zidovudine (AZT), avoid efavirenz (EFV)
63
List 3 physiological changes to the heme system that occur during pregnancy
Increase in circulating plasma volume (dilutional anemia)
Increase in leukocyte count, but impaired immune function (autoimmune disease improve)
Decrease in platelet count, but overall increase in clotting factors and hypercoagulability
64
List 4 ddx for anemia in pregnancy
Dilutional, iron deficiency, folate deficiency, sickle cell
65
List 6 risk factors for the development of folate deficiency in pregnancy
Multiple gestations, anticonvulsant medication, malnutrition, hyperemesis, alcoholism, poor leafy green intake
66
List 3 physiological changes to the cardiovascular system in pregnancy
Resting HR increases (due to decrease in BP mid pregnancy)
Increase in cardiac output
ECG changes: T wave flattening, T wave inversions in lead III, lead axis deviation, short PR, increased HR
67
List 4 differentials for chest pain in pregnancy
ACS, PE, aortic dissection, SCAD, vasospasm, biliary colic
68
List 3 changes to the management of ACS in the pregnancy patient
Avoid hypotension with nitrates
Avoid beta blockers in T1
Caution with thrombolysis in late pregnancy, this will prevent surgery or epidural anesthesia. Caution if dissection is suspected
69
List 3 physiological changes to the respiratory system during pregnancy
Increased tidal and minute volume
Respiratory alkalosis (pCO2 28-32, pH 7.40-7.45) with a chronic metabolic compensation through lower bicarb
Decreased in inspiratory and expiratory reserves due to displacement of the chest
70
List 4 common maternal adverse outcomes that result from chronic medical disease during pregnancy
Preterm labour, prematurity, PROM, need for C section, pre-eclampsia
71
List 4 common fetal adverse outcomes that result from chronic medical disease during pregnancy
IUGR, fetal loss, preterm delivery, low birth weight (exception diabetes), fetal hypoxia (asthma)
72
What 3 interventions should you avoid in a pregnant patient with thyroid storm
Methimazole (PTU preferred), Iodide (will destroy fetal tissue, hydrocortisone is sufficient), radioactive ablation (destroys fetal thyroid)
73
List 3 unique complications of pregnancy in a patient with a spinal cord injury
DVTs, UTIs, autonomic dysreflexia (must be higher than T5-6), masked labour (must be higher than T10)
74
When is a fetus most sensitive to drug effects
Organogenesis, day 21-56, week 3-8
CNS is most affected during weeks 10-17
75
A woman at 32 weeks presents with a chronic pain. What is the ideal analgesia? List 2 agents that should be avoided and explain why
Tylenol
NSAIDs are avoided in 3rd trimester (tocolytic) and 1st trimester (risk of spontaneous abortion, cardiac septal defects), premature closure of ductus arteriosus)
Opioids should be avoided near term due to respiratory depression of the infant and neonatal abstinence syndrome
Ergotamines
76
What is fetal warfarin syndrome
Dose dependent, highest risk weeks 6-9, may result in corpus callosum agenesis, hypoplasia of nasal bones, optic atrophy and blindness, CNS malformations, fetal intraventricular hemorrhage, stillbirths, spontaneous abortion
77
Name one antidote contraindicated in pregnancy
Methylene blue: can cause hemolytic anemia, hyperbilirubinemia, methemoglobinemia, jejunal atresias
78
List 3 antibiotic classes preferred in pregnancy
Cephalosporins, penicillins, macrolides (ex. azithromycin), metronidazole
79
List 3 antibiotic classes avoided in pregnancy
Fluoroquinolones (cardiac defects during T1), sulfa (hemolytic anemia, kernicterus, neural tube defects), tetracyclines (fetal bone development, teeth discolouration, Aminoglycosides
80
What is the preferred antifungal agent in pregnancy? What drug should be avoided
Nystatin is preferred
Fluconazole should be avoided due to craniofacial and cardiac defects. Okay if given intravaginally
81
Name one antiarrhythmic that should be avoided in pregnancy
Amiodarone (congenital abnormalities esp. thyroid, has a high concentration of iodine)
82
What is the vasopressor of choice in pregnancy
Phenylephrine
83
List 10 known teratogens
Isotretinoin, warfarin, methotrexate, methylene blue, phenytoin, valproic acid, rosuvastatin, simvastatin, NSAIDs in 3rd trimester, sulfonamides, tetracyclines, fluoroquinolones
84
List 3 reassuring findings on fetal heart tracing
Rate 110-160, moderate variability (5-25 bpm), accelerations
85
List 3 concerning findings on fetal heart tracing
Rate <110 or >160, minimal, marked or sinusoidal variability, late decelerations
86
List 3 maternal and 3 fetal findings that can affect fetal heart tracing
In general FHR is used as a surrogate for fetal oxygenation status
Maternal: respiratory status, smoking, positioning, anemia, hypotension, placental abruption, chorio
Fetal: cord compression, acidemia, oligohydramnios, drugs
87
What causes 1) early 2) variable and 3) late decelerations
Early: head compression, transient
Variable: cord compression
Late: uteroplacental insufficiency
88
List 3 maneuvers that can be used to help manage a cord prolapse
Knees to chest, elevate presenting part (ex. head down in Trendelenburg), tell mother to refrain from pushing, Foley + 500-750 ml of warm saline into the bladder to help lift the fetus off the cord
89
Describe the maneuvers used to deliver a baby
Deliver the head -> gentle downward traction on the head to deliver the anterior shoulder -> gentle upward pull on the anterior shoulder for the posterior shoulder -> clamp and cut the cord
90
List the components of the APGAR score
Activity: 0 absent, 1 arms and legs flexed, 2 active
Pulse: 0 absent, 1 <100, 2 >100
Grimace: 0 none, 1 grimace, 2 sneezing/coughing/pulling away
Appearance: 0 blue/gray, 1 normal except at extremities, normal over body
Respirations: 0 none, 1 slow/irregular, 2 good/crying
91
Baby comes out, grimacing and with arms and legs flexed, but HR >100, normal colour, and crying. What is the baby's APGARS
8
92
List 4 etiologies for labour dystocia
Power (hypertonic contractions), Passenger (fetal position, large size), Passage (pelvic structure), psyche (anxiety/pain)
93
List 4 risk factors for shoulder dystocia
Maternal: previous shoulder dystocia, operative delivery, diabetes, obesity, narrow pelvis
Fetal: macrosomia, postmaturity, erythroblastosis fetalis
94
List 4 complications of shoulder dystocia
Maternal: perineal and sphincter tears, urinary incontinence
Fetal: brachial plexus injuries, clavicle fractures, hypoxic brain injuries
95
Name 1 manuever that can help in a breech presentation
Maurice maneuver: Place fingers on maxillary sinuses to help guide the head; flex the fetal neck and draw in the chin - do not pull
96
What is the definition of postpartum hemorrhage
>500 cc via vaginal delivery, >1 L after C section, any amount of bleeding that causes hemodynamic instability
97
List 4 medications that can be used in the management of postpartum hemorrhage
Oxytocin (prolonged half life) 10 U IM after the delivery of the anterior shoulder (a second dose or 20-40U in IL NS wide open or 5-10 US IV bolus over 1-2 mins)
Misoprostol (800 mcg PR, PO, or SL)
Ergotamine Ergot (0.25mg IM or IV, may repeat 2-4H intervals
Prostaglandin Hemabate/Carboprost (0.25mg IM x 8 q 15 min; can be injected directly into the uterus), prostaglandin
Tranexamic acid
98
List 3 physical maneuvers that can be done in a woman with postpartum hemorrhage
Tamponade with bimanual massage, uterine packing, remove clots/placenta tissue, Bakri balloon, Blakemore balloon, Foley with 80 ml of NS
99
Describe the evidence for TXA in postpartum hemorrhage
WOMAN trial
Population: 20,060 women were enrolled in 23 countries. Randomized, placebo controlled trial
Intervention: 1g IV TXA or matching placebo, w a 2 dose if bleeding continued for > 30 mins
Control: placebo
Outcomes: No change in original primary outcome; death from all causes of hysterectomy. 2ndary outcomes include death due to bleeding was significantly decreased in the TXA group (1.5 vs. 1.9%). This was the revised outcome
Bottom line: -ve trial as originally designed. Small effect but no adverse effects and inexpensive drug; worth considering
100
List 8 risk factors for premature labour
Maternal: short cervix, placenta previa, placenta abruption, extremes of age, prior preterm birth
Baby: multiple gestation, antepartum hemorrhage, PROM, polyhydramnios, fetal hydrops, congenital abnormalities of the fetus, cervical incompetence
Pre-existing: hx of preterm birth, smoking, infection, HTN, GDM, previous surgery, substance abuse, psychosocial stressor
101
What is the criteria for fetal viability
24-46 weeks, EFW 500g [Rosens]
22 weeks [SOGC]
102
Describe the changes in vitals that can be expected in the pregnant patient
HR increases by 10-15 beats, BP lowers by 5-15 by the second trimester (normal by the third trimester)
103
Describe an important modifier for the pregnant patient during CPR
Uterine displacement to the left
104
What is the clinical presentation of placental abruption
Little to no signs of external injury. May present with vaginal bleeding, pain, uterine tenderness, and fetal distress (fetal distress is the most sensitive sign). Risk of DIC. Most common cause of fetal loss
105
List 5 side effects of trauma in the pregnant patient
Placental abruption, uterine contractions, uterine shock, amniotic fluid embolism, fetomaternal hemorrhage, direct fetal injury, DIC
106
What is the most common side effect of trauma in the pregnant patient
Uterine contractions
107
Describe modifications to ATLS in the pregnant patient
Airway: assume difficult intubation, pre-oxygenation, increased risk of aspiration
Breathing: chest tubes should be higher, vent settings should be adjusted for tachypnea of pregnancy (target PaCO2 of 30)
Circulation: place patient in in left lateral decubitus, physiologic increased cardiac output. Solid organs are all displaced upwards and maybe more vulnerable to injury. Avoid vasopressors (decreases flow to the placenta)
Assessment of the baby does not come until secondary survey (fetal heart tones, no digital exam)
108
How long should the pregnant patient be observed post trauma
4 hours of fetal monitoring with NST. Should be extended to 24 hours if uterine tenderness, abdominal pain, vaginal bleeding, uterine contractions, rupture of membranes, atypical or abdominal fetal heart rate, high risk injury, low serum fibrinogen
109
What additional blood work would you order in a pregnant trauma patient
Kleihauer-Betke, blood/Rh type, coags, fibrinogen (high risk of DIC)
110
What is the dose of Rhogam? When should it be given?
50mcg (DID WE DECIDE ITS 300? SOURCE?) in 1st trimester, 300mcg after than, should be given within 72 hours
300mcg in all traumas regardless of first trimester as per SOGC
111
Describe the process of a resuscitative hysterotomy
Indications: ACLS for 4 minutes with uterus >umbilicus
1. Continue CPR with the mother throughout the resuscitative hysterectomy
2. Large incision for epigastrium to symphysis through the peritoneum
3. Vertical incision in the uterus (thinner in lower segments) or try using scissors
4. Fundal pressure, deliver baby, clamp and cut cord
5. Take the placenta out
5. Pack/close the uterus. Postpartum hemorrhage management
112
What are expected ECG changes in pregnancy
Left axis shift, flattering of T waves, Q waves in lead III
113
What is a safe radiation dose to the fetus
50 mGy (all scans <50 mGy) this is a 2% lifetime risk of cancer with no evidence of fetal malformation
